Skip to content Home About Programs and Plans Resources Services Environmental Services Hazardous and Non-Hazardous Materials Disposal Storm Water Fire Safety Health and Safety Training Union Management Safety Committee Worker's Compensation Directory Contact Us Accident / Injury / Incident Report (311 Form) Please use the form below to report all incidents, injuries and illnesses.If you are reporting a fatality, amputation, loss of an eye or overnight hospitalization, call (269)387-5588 immediately. Then complete the form below. Name of Injured Person (required) Please use the injured party's full name, no nicknames or acronyms. Is the injured party completing this form? (required) Yes No What is the injured party's affiliation to the university? (required) Employee Student Employee Student Visitor Contractor Is this injury or illness work related? Yes (Incident likely occurred as a result of job duties) No (or unsure) Job Title (required) - Select -Administrative/ProfessionalDining ServicesFaculty/ProfessorsSkilled Trades (FM)Landscape ServicesCustodian (BCSS)Materials and Handling (Stockroom)Health CarePower PlantPolice and ParkingCoaching and Training (Athletics)Student EmployeesStudent (Non-Employee)Visitor (Non-Employee) Department (required) - Select -Custodial (BCSS)DiningLandscapeMaintenance (FM)Alumni Affairs and DevelopmentAuxiliary enterprisesBusiness & Finance -- GeneralCenter for Disability ServicesCollege of Arts and SciencesCollege of AviationCollege of Business (HCOB)College of EducationCollege of Engineering and Applied SciencesCollege of Fine ArtsCollege of Health & Human ServicesMARCOMMerze Tate CollegeConstruction/Remodel ShopDean of StudentsKalamazoo Autism CenterIntercollegiate AthleticsLibrariesLogistical ServicesMulticultural AffairsOffice for SustainabilityOffice of Information TechnologyOffice of the PresidentPolice and parkingPower PlantProvostResearch and Sponsored ProgramsResidence Life/Student AffairsSindecuse Health CenterStudent (non-employee)Transportation (Garage)Visitor蜜桃社区x Home Address (required) Include Street Address, City, State and Zip Code. Home or Cell Phone Number (required) Enter number with no dashes or spaces: ########## Date of Injury or Illness (required) Time of Injury or Illness What time did the injured party start work? Location of Incident (required) - Select -Ackley Hall V IAlliance Senior ServicesArcadia Flats (new)Bella Vita Cafe' (at CHHS)Bernhard Cafe' (at Bernhard Center)Bernhard CenterBill BrownBobb StadiumBritton Hall V IBronco MallBrown HallBurnhamBurnham Dining ServicesCafe' 1903 (at VDC)Campus Services BuildingCampus wideCenter for Disability Services CDSChemistry BuildingCoating Pilot PlantCollege of Aviation (Battle Creek)College of Health and Human ServicesCollege of Engineering and Applied SciencesDalton CenterBistro 3 Davis DiningDavis HallDraper DiningDraper HallDunbarEbert FieldEicher V IIEldridge V IIIEllsworthEverett TowerEWBFaunce Student Services BldgFetzer CenterFlossie's Cafe' (at Sangren Hall)French HallFriedmann HallFox Hall V IIIGarneau V IIGilmore HouseGilmore Theater ComplexGoldsworth Valley ApartmentsGrand Rapids East BeltlineGrand Rapids DowntownHadley Hall V IHaenickeHarrison Hall V IIIHarvey V IIHaworth College of BusinessHenry HallHeritage HallHyames FieldIntramural FieldsKalamazoo Autism CenterKanley ChapelKanley TrackKendall CenterKnauss HallKohrman - CentralKorhman - NorthKorhman - SouthLawson ArenaLee Honors CollegeLefevre Hall V IIMGREEMiller AuditoriumMiller PlazaMontague HouseMoore HallOakland GymOff campusOffice for SustainabilityOther (Please Specify)OutsideParking Services GarageParking LotParking ServicesParkview Cafe' (at CEAS)Physical PlantPlaza Cafe' (at Sprau Tower)Power PlantPresidents ResidencePress boxPublic SafetyRead Field HouseRichmond Center RCVARood HallSalt DomeSangren HallSchneider Cafe' (at Schneider Hall)Schneider HallSeeyle CenterSeibert Admin BldgShaw TheatreShilling Hall V ISiedschlag HallSindecuse Health CenterSoftball FieldSouth pump houseSpindler HallSprau TowerStadium Drive AptStinson V IIIStudent Rec CenterStudent Center (new)The OaklandsTrimpeUnified ClinicsUniversity ArenaUniversity Computer Center UCCUnknownUpholstery ShopValley IValley IIValley IIIValley Dining CenterVandercookWaldo LibraryWaldo StadiumWalwood HallWelborn HallWest Hills AC蜜桃社区 Heights East蜜桃社区 Heights West蜜桃社区 View Apartments蜜桃社区 Bookstore Wood HallZhang Legacy CollectionZimmerman Specific Location of Incident (required) Please indicate what room or floor the incident occurred in. Did the injured party receive medical treatment? (required) (Select "Yes" if they are going to see or went to see a health professional. Select "No" if the person received first aid that occurred on site or no assistance.) Yes No Maybe Later Where did the injured party receive medical treatment? - None -Sindecuse Health CenterBattle CreekAscension BorgessBronsonWestside Family MedicalOther Was the injured party treated in the emergency room? Yes No Was the injured party hospitalized overnight as an in-patient? Yes No Unknown What was the injured person doing just before the incident occurred? (required) Describe the activity, as well as the tools, equipment or material the person was using. Be specific. Examples: "climbing a ladder while carrying roofing materials", "spraying chlorine from hand sprayer", "daily computer entry." What happened? (required) Tell us how the injury occurred. Examples: "When ladder slipped on wet floor, worker fell 20 feet", "Worker was sprayed with chlorine when gasket broke during replacement", "worker developed soreness in the wrist over time." What body part or parts were affected? (required) AbdomenAnkleArmBackBack LowerBrainButtocksCheekChestDigestive SystemEar (not hearing)ElbowEye (not sight)FaceFingerFootForearmHandHead (not brain)HeartHipInternalKidney Bladder IntestineKneeLegLungsMouth (not teeth)NeckNervous SystemNose (not sense of smell)Other (please describe in "what happened")Pelvic or GroinReporting Near Miss OnlyRibsScalpShoulderSkullSpineTooth or TeethThighThroatThumbToe or ToesTongueUnknownWrist You may choose more than one body part. (Hold down the Ctrl key to select multiple choices.) Side of the Body (required) Which side of the body did the injury occur? Left Right Bilateral (Both Sides) Not Applicable Other Other Injury Details Use this field to document anything additional regarding the injury. You can also use this field to list body parts that are not in the drop down menu. What was the injury or illness? (required) Abrasion/Scrape/Scratch/IrritationAmputationBite from AnimalBite/Sting from InsectBite from PersonBreathing Problems or CoughBurn (not chemical)Chemical BurnConcussionCOVID-19Contusion/BruiseCrushDeathDermatitis/Hives/Rash (includes poison ivy, not-chemical)Digestive IssuesDislocationElectric ShockEmotionalForeign BodyFracture/BreakFrostbite/FreezingHeat ExhaustionHeat StrokeHeart problemsHearing LossHerniaInfectionInhalation ExposureLaceration or cutLoss of ConsciousnessNausea with or without VomitingNear MissNeedlestickNumbnessOtherParalysisPsychologicalPunctureRadiation (not from sun)RuptureSeizureSprain or StrainStrokeSunburnUnknown Choose all that apply. Press and hold the Ctrl key to select multiple choices. What was the object or substance that directly harmed the person? (required) Examples: "concrete floor", "chlorine", "radial arm saw." Photo Documentation Upload Please upload photos of the injury source, location-area, or anything else that may be helpful. One file only.100 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods, xml, avi, mov, mp3, ogg, wav. What could be done to prevent this kind of incident in the future? Additional Info Is there any additional information you would like to add before submitting this incident? Witnesses Were there any witnesses? Please tell us their name(s) and phone number(s). Employee's Supervisor (required) Supervisor at the time of the incident. Employee's Supervisor's Phone Number (required) Please enter phone number with no spaces or dashes ########## Supervisor's WMICH Email (required) Injured Party's WMICH Email Address (required) Add the employee's wmich.edu email address if they wish to have a copy of this report sent to them. Department Director Email (required) Department Director Email Department Director Email Item weight Add Add more items more items Use this box to enter an email address used by your department director. Separate additional email addresses with commas. Submit Leave this field blank
